Washington State University

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1 One Delaware Drive Salem, NH Washington State University Study Abroad Insurance Program Blanket Student Accident and Sickness Insurance This pamphlet contains a brief summary of the features and benefits for insured participants covered under Policy No. B0755G40133A. This is not a contract of insurance. Coverage is governed by an insurance policy issued to Washington State University. The policy is underwritten by Inter Hannover. Complete information on the insurance is contained in the Certificate of Insurance on file with the school. If there is a difference between this program description and the certificate wording, the certificate controls. One Delaware Drive Salem, NH

2 Your Accident and Sickness Insurance Plan Summary Eligibility Students, faculty or staff participating in, or traveling on behalf of, a study abroad program outside of the United States sponsored by the participating organization for a length of time not to exceed one semester. When an Eligible Participant s Coverage Starts Coverage for an Eligible Participant starts at 12:00:01 a.m. on the latest of the following: 1. The effective date shown on the Insurance Identification Card, if any; 2. The date the requirements in Section 1 - Eligible Classes are met; or 3. The date the premium and completed enrollment form, if any, are received by the Insurer or the Administrator. Thereafter, the insurance is effective 24 hours a day, outside of the United States. In no event, however, will insurance start prior to the date the premium is received by the Insurer. When an Eligible Participant s Coverage Ends Coverage for an Eligible Participant will automatically terminate at 11:59:59 pm on the earliest of the following dates: 1. The date the Policy terminates; 2. The Participating Organization s or Institution s Termination Date; 3. The date of which the Eligible Participant ceases to meet the Individual Eligibility Requirements; 4. The date the Eligible Person returns to the United States; 5. The date the Eligible Participant requests cancellation of coverage (the request must be in writing); or 6. The premium due date for which the required premium has not been paid, subject to the Grace Period provision. 7. The end of any Period of Coverage. In the event of a medical emergency All Covered Persons are entitled to Global Assistance Services while traveling outside of the United States. In the event of an emergency, you should go immediately to the nearest physician or hospital without delay and then contact On Call International. If you are not sure where the nearest medical facility is, you can contact On Call for a referral. On Call International will then take the appropriate action to assist and monitor the medical care until the situation is resolved. To contact On Call in the event of an emergency, call or collect to On Call must pay and arrange all Global Assistance Services, these expenses are not reimbursable. In the event of a political or natural disaster event which threatens your safety All Covered Persons are entitled to Global Assistance Services while traveling outside of the United States which includes political and natural disaster evacuation, as well as security and safety advice. If you feel unsafe or experience a direct threat to your safety, contact On Call immediately, you will be connected to a security professional that will provide immediate advice to maintain safety and then assess your situation to determine appropriate next steps. Claims Submission Claims are to be submitted to On Call International, One Delaware Drive, Salem, New Hampshire or Visit login: WSUstudy, password: oncall135 to download claim forms and instructions on how to file. Note that only claims for Medical Expenses and Accidental Death and Dismemberment will be considered, On Call must pay and arrange for any International Assistance Services, expenses associated with these services are not reimbursable. Coordination of Benefits If you have health care coverage through more than one medical insurance plan at the same time, this plan will be primary when traveling outside the United States. On Call will attempt COB. This allows On Call and other plans to work together so the total amount of all benefits will never be more than 100 percent of the allowable expenses during any policy year.

3 SCHEDULE OF BENEFITS All benefits and limits are stated per Covered Person. Choice of Hospital and Physician: Nothing contained in this Plan restricts or interferes with the Eligible Participant s right to select the Hospital or Physician of the Eligible Participant s choice. Also, nothing in this Plan restricts the Eligible Participant s right to receive, at his/her expense, any treatment not covered in this Plan. MEDICAL BENEFITS Period of Coverage Maximum Benefits $500,000 Maximum Benefit per Injury or Sickness $500,000 Physician Office Visits Hospital and Other Services Emergency Room and Outpatient Surgical Facilities Services Benefits listed below are subject to the Period of Coverage Maximum and the Maximums per Injury and Sickness. Please see the Certificate of Coverage, Section 3, for detailed descriptions of the benefits listed below. Pregnancy Mental, Emotional or Functional Nervous Disorders Benefits are payable at the same rate as for Physical Illness, subject to the limitations stated in the Schedule of Benefits: Mental illness shall be limited to those disorders identified in the most recent edition of the International Classification of Diseases of the Diagnostic and Statistical Manual of the American Psychiatric Association. Chemical Dependency Coverage for Medically Necessary treatment and supporting services for a Covered Person in an approved chemical dependency treatment program. The benefit is limited to $15,500. These limits do not apply to Medically Necessary detoxification provided in a Hospital unless the Covered person is currently enrolled in a chemical dependency treatment program. Treatment of specified therapies, including acupuncture and Physiotherapy up to $10,000 Maximum combined total for Inpatient and Outpatient care, up to 30 days immediately following the attending Physician s release for rehabilitation following a covered Hospital confinement or surgery per Period of Coverage Therapeutic termination of pregnancy up to $500 maximum per Period of Coverage Elective termination of pregnancy up to $300 maximum per Period of Coverage Routine nursery care of a newborn child of a covered pregnancy up to $500 maximum per Period of Coverage

4 MEDICAL BENEFITS Annual cervical cytology screening Mammography screening when screening for occult breast cancer is recommended by a Physician Prostate screening tests Dental Anesthesia Breast Reconstruction due to Mastectomy Low Protein Modified Food Products Dental Care for an Accidental Injury up to $2,500 maximum per Period of Coverage maximum Outpatient prescription drugs including oral contraceptives Diabetic Supplies/Education Other Coverages Maximum Benefit: Principal Sum- Accidental Death & Dismemberment Eligible Participant: up to $10,000 Partner: up to $5,000 Child: up to $1,000 GLOBAL ASSISTANCE BENEFITS Medical Evacuation Maximum Lifetime Benefit for all Evacuations up to $250,000 Bedside Visit Up to a maximum benefit of $20,000 for the cost of one economy roundtrip air fare ticket to, and the hotel accommodations in, the place of the Hospital Confinement for one (1) person Repatriation of Remains Maximum Benefit up to $50,000 Political and Natural Disaster Evacuation Food and Lodging in Safe Haven and Return to Home or Alternate Study Location following PND evacuation 24 Hour Medical, Travel and Security Assistance Maximum Benefit up to $100,000 Maximum Benefit up to $5,000 includes food/lodging up to $150 per day for a maximum of three days Unlimited access to assistance services including pre-trip advice, medical referrals, medical monitoring, location of lost luggage or travel documentation, legal consultation and referral and interpreter assistance

5 GENERAL POLICY EXCLUSIONS Unless specifically provided for elsewhere under the Plan, the Plan does not cover loss caused by or resulting from, nor is any premium charged for, any of the following: No benefits will be paid under this plan for expenses incurred inside the United States. Preventative medicines, routine physical examinations, or any other examination where there are no objective indications of impairment in normal health, unless otherwise noted. Services and supplies not Medically Necessary for the diagnosis or treatment of a Sickness or Injury, unless otherwise noted. Surgery for the correction of refractive error and services and prescriptions for eye examinations, eye glasses or contact lenses or hearing aids, except when Medically Necessary for the Treatment of an Injury. Plastic or cosmetic surgery, unless they result directly from an Injury which necessitated medical treatment within 24 hours of the Accident. For diagnostic investigation or medical treatment for infertility or fertility. Expenses incurred in excess of. Organ or tissue transplant. Expenses incurred from participating in an illegal occupation or committing or attempting to commit a felony. While traveling against the advice of a Physician, while on a waiting list for a specific treatment, or when traveling for the purpose of obtaining medical treatment. The diagnosis or treatment of Congenital Conditions, except for a newborn child insured under the Policy. Treatment to the teeth, gums, jaw or structures directly supporting the teeth, including surgical extraction s of teeth, or skeletal irregularities of one or both jaws including orthognathia and mandibular retrognathia. Expenses incurred in connection with weak, strained or flat feet, corns or calluses. Diagnosis and treatment of acne and sebaceous cyst. Deviated nasal septum, including submucous resection and/or surgical correction, unless treatment is due to or arises from an Injury. Loss due to war, declared or undeclared; service in the armed forces of any country or international authority; participation in a riot or civil commotion. Riding in any aircraft, except as a passenger on a regularly scheduled airline or charter flight. Loss arising from participation in professional sports, scuba diving, hang gliding, parachuting, or bungee jumping. Medical Treatment Benefits provision for loss due to or arising from a motor vehicle Accident if the Covered Person operated the vehicle without a proper license in the jurisdiction where the Accident occurred. Under the Accidental Death and Dismemberment provision, for loss of life or dismemberment for or arising from an Accident in the Covered Person s Home Country. Expenses incurred prior to the beginning of the current Period of Coverage or after the end of the current Period of Coverage except as described in Covered General Medical Expenses and Limitations and Extension of Benefits.

6 POLITICAL AND NATURAL DISASTER EVACUATION EXCLUSIONS On Call will not be liable for any expenses resulting from: Participant s or Client s failure to reasonably prove that there is any threat to the Insured Person s safety. Participant taking part in any political activity or operations of any security or armed forces unless declared to and agreed by On Call. 3. Or attributable to an alleged violation of the laws of the Country of Residence by Participant or the Insured Person. 4. Participant s failure to maintain and possess duly authorized and issued required immigration, work, residence or similar visas or permits or other relevant documentation required in the Participant s Country of Residence. 5. Accommodation or Evacuation Expenses incurred more than 30 days after the Covered Event. 6. Or attributable in whole or in part to a debt insolvency, commercial failure, the repossession of any property by any title holder or lien holder, or any other financial cause. 7. Participant s failure to honor any contractual obligation bond or specific performance condition in a license. 8. Participant at inception of this policy having prior knowledge of or had received information of any specific matter, fact or circumstance which would lead to an Covered Event that has not been declared to and accepted by On Call. 9. Any Losses incurred by Participant that have been increased by Participant s failure to follow the advice of On Call. 10. Any losses that have been increased by the Client s or Participant s failure to follow the advice of Our Crisis Management Company promptly.

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